Form Mdes-13 - Internet - Report To Determine Liability For Unemployment Tax Page 2
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2REPORT TO DETERMINE LIABILITY FOR UNEMPLOYMENT TAX (continued)
__ __ __ __ __ __ __ - __ __
Minnesota Unemployment Tax Account Number if assigned:
-
16.
Succession: Complete this section if you have acquired, purchased, leased, or assumed all or any part of an existing
Minnesota business. This includes a new legal entity formed through reorganization by substantially the same ownership.
New legal entity formed by substantially the same ownership by reorganization (i.e. sole proprietorship to corporation).
Acquisition, purchase, lease, or assumption of all or any part of an existing Minnesota business or its assets.
Corporate stock changed hands without formation of a new corporation.
17.
Date of reorganization or acquisition:
18.
Trade name and full street address of business acquired:
19.
Minnesota Unemployment Tax Account Number of previous business, if known:
-
-
20.
Name, address, and telephone number of previous owner:
Telephone:
(
)
21.
Is the previous owner (predecessor) still doing business in Minnesota?
Yes
No
Unknown
22.
What percentage of your predecessor’ s assets did you acquire?
23.
How many of your predecessor’ s employment
How many have
positions have you continued?
you not continued?
24.
Is there 25% or more common ownership between the new business (successor) and the previous business (predecessor)?
Common ownership includes ownership by a spouse, parent, child, brother, sister, aunt,
Yes
No
uncle, niece, nephew, or first cousin, by birth or by marriage, or adoption.
Corporations, refer to instructions.
A.
If yes, list the owners that are common to both the predecessor and the successor and their relationship. For each of these
common owners, identify the percentage of ownership in both the predecessor and successor businesses.
Predecessor Owner
% of Pred
Successor Owner
% of Succ
Relationship
Ownership
Ownership
B.
If you answered yes to #24 and you acquired only a portion of your predecessor’ s business, do you wish
Yes
No
to apply for that portion of your predecessor’ s employment experience by furnishing payroll information?
25.
Ownership: Please print or type. This report must be signed by the owner, all partners, or authorized officers. Attach
additional sheets if necessary.
I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.
Full Legal Name
Title
Social Security #
% of Ownership
Home Address
City
State
Zip Code
Signature
Phone #
Date
Full Legal Name
Title
Social Security #
% of Ownership
Home Address
City
State
Zip Code
Signature
Phone #
Date
26. Name and title of form preparer
Phone #
Date
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